Sun Life Insurance and Annuity Company of New York
Short Term Disability Claim Packet
Instructions for the Plan Administrator
An initial claim for Short Term Disability benefits should be submitted when a disability absence has actually begun, and it first appears that the eligible employee’s disability will extend beyond the required elimination period. To file a Short Term Disability Claim, prefill Section A: Employer’s Statement. Then, provide the entire claim packet to the employee. The employee should make sure all of the sections are complete including the Physician Statement. Then, he or she should mail or fax the completed claim form to:
Sun Life Insurance and Annuity Company of New York Group Short Term Disability Claims
P.O. Box 81915
Wellesley Hills, MA 02481 Tel: 1-800-247-6875 Fax: (781) 304-5599
Failure to provide complete and accurate information could result in the need for additional claims investigation which could delay the initial benefit payment.
Section A: Employer’s Statement 1 General Information
Name of employer
Group policy number
Class Name of employee (first, middle initial, last) M
F
Social Security number
Date of birth Please print clearly.
Name and address of Division where employee works
Employee phone no.
2 Employment and Claim Information Date hired (m/d/y)
Effective date of insurance
Date last worked
Hours worked last day
Job title / Major job duties (Or, attach employee’s formal job description)
Regularly scheduled work week:
Days per week: Hours per day:
How long had employee been in occupation? Years: Months:
Has the employee’s employment been terminated? Yes No
If yes, provide termination date
Why did employee cease working?
Be sure to include all salary information.
2 Employment and Claim Information continued
How would you classify this employee’s occupation?
Sedentary (1-10 lbs) Light (11-20 lbs) Medium (21-50 lbs) Heavy (51+ lbs)
Is the condition due to an injury or sickness arising out of employee’s job?.... Yes No Disputed
Has a Workers’ Compensation claim been filed? ... Yes No
If “yes,” please include the initial report of illness/injury and award/denial notice with this claim. Name of your Workers’ Compensation carrier:
Phone number
Has employee returned to work?
Yes No If yes: With restrictions Full capacity
Date returned
3 Salary and Benefits Information
How was the employee paid? (check one) Provide information about other income: Hourly
$ per hour:
Salaried
$ per week:
Commissions
$
Bonuses
$
Overtime
$ Does employee contribute toward the STD premium? ... Yes No
y If “yes,” attach a copy of employee’s enrollment form
to this claim and indicate percentage contribution...
Employee: %
Employer: % Indicate whether or not
the employee contributes to the STD premium on a pre- or post-tax basis.
y Are employee contributions made with pre-tax dollars?... Yes No
4 Information About Other Income
Is employee currently receiving, or entitled to receive, benefits from any of the following sources?
Source of income
Amount of each payment
Weekly or monthly?
Period/date(s) covered by
payment
Vacation pay $ Wkly Mthly
Sick pay $ Wkly Mthly
State Disability $ Wkly Mthly Check all that apply
and provide details for each source of income.
Other: $ Wkly Mthly
5 Certification and Signature
I certify that the above statements are true and complete. I have read and understand the Fraud Warning on page 6 of this packet.
Name of person completing this form
Telephone number
E-mail address
Tip: To certify eligibility, mail or fax the employee’s enrollment form
with the claim. Signature X
Title
Date signed
For more information about Short Term Disability, the claim process and the status of your employees’ claims, log onto CustomerLink at https://customerlink.sunlife-usa.com
Sun Life Insurance and Annuity Company of New York
Short Term Disability Claim Packet
Section B: Employee’s Statement 1 General Information
Your name (first, middle initial, last) M
F
Social Security number
Date of birth Your street address
City
State
Zip Code Your occupation
Telephone Number
Provide your full address and Social Security number. Please print clearly
Employer Name
Group Policy Number
2 Information About the Condition Causing Your Disability
Type (check one): Pregnancy Motor vehicle accident Work-related injury/sickness Sickness Other accident
Describe in detail how, when and where the accident occurred –OR – Describe the nature of your illness/condition and its first symptoms. If work-related, describe cause of injury/illness.
Date you were first treated by a physician
Last day worked prior to disability
Did you work Yes a full day? No Name of your first treating physician
Physician phone number
Name of hospital
Hospital phone number
Date(s) of confinement
Date first unable to work
Date you expect to return to work
Do you expect to return full- or part-time? Full-Time Part-Time
Reminder: Return completed claim packet (including Attending Physician Statement) and all required
documentation to: Sun Life (N.Y.) Group STD Claims P.O. Box 81915
Wellesley Hills, MA 02481 Tel: 1-800-247-6875 Fax: (781) 304-5599
If work-related, have you filed/do you intend to file, a Workers’ Compensation claim?.... Yes No
3 Information About Other Income
Are you currently receiving, or entitled to receive, benefits from any of the following sources?
Source of income
Amount of each payment
Weekly or monthly?
Period/date(s) covered by payment
Vacation pay $ Wkly Mthly
Sick pay $ Wkly Mthly
State Disability $ Wkly Mthly Check all that apply
and provide details for each source of income.
Other: $ Wkly Mthly 4 Signature
I certify that the above statements are true and complete. I have read and understand the Fraud Warning on page 6 of this packet.
Employee’s signature X
Date signed
Reminder: Please be sure to sign and return any Authorization statements included in this packet.
Sun Life Insurance and Annuity Company of New York
Short Term Disability Claim Packet
Section C: Attending Physician’s Statement 1 Information About the Patient
The patient is responsible for any costs associated with the completion of this form. Name of Patient (first, middle initial, last) M
F
Social Security number
Date of birth (m/d/y)
Please print clearly
Name of Employer
Group Policy number
Employee phone no.
2 Diagnosis and History
Diagnosis including any complications and ICD-9 Codes(s)
Objective findings (i.e. x-rays, EKGs, MRIs, laboratory data and any other clinical findings)
Subjective Symptoms
Date symptoms first appeared or date of accident
Date Disability Commenced
Has patient ever had same or similar condition? ... Yes No If Yes, when: Is condition due to injury/sickness arising out of patient’s employment? ... Yes No Unknown Names and telephone numbers of Other Treating Physicians (if applicable)
If pregnancy, please provide the following information:
y Expected delivery date: y Actual delivery date: y C-Section? Yes No
Provide general information about diagnosis and history in this section. Then, please elaborate in section(s) 3 – 6 as appropriate.
Describe any complications that would extend this disability longer than a normal pregnancy
3 Treatment
Date of first visit
Date of last visit
Date of last examination
Frequency of treatment ... Weekly Monthly Other (please specify: ) Include in description
any surgery, thera- peutic modalities, psychological inter- vention and medic- ations prescribed.
Description of Treatment
4 Progress
Has patient: ... Recovered Unchanged Improved Retrogressed
Is patient:... Ambulatory Bed confined House confined Hospital confined If unchanged or retrogressed, please explain:
Has patient been hospital confined? ... Yes No From: To: If yes, provide name and address of hospital
5 Restrictions and Limitations
Restrictions (what the patient should not do)
Limitations (what the patient cannot do)
Is the patient capable of working within these restrictions/limitations? ... Yes No
Can the patient work an eight-hour day with these restrictions/limitations? ... Yes No
If no, how many hours could he/she work? ... hours Is patient capable of working in another occupation?... Yes - Full-time Yes - Part-time No
Physical Impairment
Class 1 – No limitation of functional capacity; capable of heavy work* No restrictions (0-10%) Class 2 – Medium manual activity* (15-30%)
Class 3 – Slight limitation; capable of light work* (35-55%)
Class 4 – Moderate limitation; capable of clerical/administrative (sedentary*) activity (60-70%) Class 5 – Severe limitation; incapable of minimum (sedentary*) activity (75-100%)
Mental Impairment (if applicable)
Class 1 – No limitation Class 4 – Marked limitation Class 2 – Slight limitation Class 5 – Severe limitation Class 3 – Moderate limitation
Axis I Axis IV
Axis II Axis V
Axis III Restrictions and
Limitations should be associated with the Objective and Subjective
findings/symptoms noted in section 2.
Indicate class of physical impairment.
* As defined in federal dictionary of occupation titles Indicate class of mental impairment.
What is the patient’s current DSM-IV-R diagnosis?
Do you believe this patient is competent to endorse checks/direct the use of proceeds?... Yes No
6 Return-to-Work
1. When will patient recover sufficiently to perform duties? (Specify date or check recovery period)
• Patient’s occupation part-time:
Date: -or- < 3 wks 3-4 wks 5-6 wks 7-8 wks 2 months or more Never
• Patient’s occupation full-time:
Date: -or- < 3 wks 3-4 wks 5-6 wks 7-8 wks 2 months or more Never
2. After reviewing the material and substantial duties of the patient’s occupation, would
you recommend vocational counseling and/or rehabilitation or job modification? ... Yes No
7 Certification and Signature
I certify that the above statements are true and complete. I have read and understand the Fraud Warning on page 6 of this packet.
Name of Attending Physician
Degree/Specialty
Street address
City
State
Zip Code Tax ID number
Telephone number
Fax number Remember to provide
your full address and Tax ID number. A stamp or signature of a person other than the examining physician is not acceptable.
Attending Physician Signature X
Date
Sun Life Insurance and Annuity Company of New York
Short Term Disability Claim Packet
Fraud Warning
State law requires that we notify you of the following:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Sun Life Insurance and Annuity Company of New York
Authorization for Release and Disclosure of Health Related Information This Authorization
complies with the HIPAA Privacy Rule. It is important for you to read, sign and submit all Authori- zations in this packet. Failure to submit all Authorizations could result in a delay during the claims process.
Return to: Sun Life (N.Y.) Group STD Claims P.O. Box 81915
Wellesley Hills, MA 02481 Fax: (781) 304-5599
I HEREBY AUTHORIZE any physician, health care provider, health plan, medical professional, hospital, clinic, laboratory, pharmacy or other medical or healthcare facility that has provided payment, treatment or services to me or on my behalf, to disclose my entire medical record and any other protected health information concerning me to the Claims Department of Sun Life Insurance and Annuity Company of New York (“the Company”) its subsidiaries, affiliates, third party administrators and reinsurers.
I understand that such information may include records relating to my physical or mental condition such as diagnostic tests, physical examination notes and treatment histories, which may include information regarding the diagnosis and treatment of human immunodeficiency virus (HIV)
infection, sexually transmitted diseases, mental illness and the use of alcohol, drugs and tobacco, but shall not include psychotherapy notes.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this Authorization, and I instruct any physician, healthcare professional, hospital, clinic, medical facility or other health care provider to release and disclose my entire medical record without restriction.
I understand that the Company will use the information it obtains to (a) administer claims; (b) determine or fulfill responsibility for coverage and provision of benefits; (c) administer coverage; and/or (d) conduct other legally permissible activities that relate to any coverage I have or have applied for with the Company.
I understand that the Company will not disclose information it obtains about me except as authorized by this Authorization; as may be required or permitted by law; or as I may further authorize. I understand that if information is redisclosed as permitted by this Authorization, it may no longer be protected by applicable federal privacy law.
I understand that: (a) this Authorization shall be valid for 24 months from the date I sign it; (b) I may revoke it at any time by providing written notice to Sun Life (N.Y.), Group Short Term Disability Claims, SC 3212, One Sun Life Executive Park, Wellesley Hills, Massachusetts, 02481, subject to the rights of any person who acted in reliance on it prior to receiving notice of its revocation; and (c) my authorized representative and I are entitled to receive a copy of the Authorization upon request.
A copy of this Authorization shall be as valid as the original. Print Name of Employee or Personal Representative of Employee
Group Policy Number
If Representative, description of your authority or relationship to employee
Signature of Employee or Personal Representative X
Date
Sun Life Insurance and Annuity Company of New York
Authorization for Release and Disclosure of Psychotherapy Notes This Authorization
complies with the HIPAA Privacy Rule. It is important for you to read, sign and submit all Authori- zations in this packet. Failure to submit all Authorizations could result in a delay during the claims process.
Return to: Sun Life (N.Y.) Group STD Claims P.O. Box 81915
Wellesley Hills, MA 02481 Fax: (781) 304-5599
I HEREBY AUTHORIZE any: physician, health care provider, health plan, medical professional, hospital, clinic, or other medical or health care facility that has provided payment, treatment or services to me or on my behalf; to disclose any psychotherapy notes relating to me to the Claims Department of Sun Life Insurance and Annuity Company of New York (“the Company”) its subsidiaries, affiliates, third party administrators and reinsurers.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this Authorization, and I instruct any physician, healthcare professional, hospital, clinic, medical facility or other health care provider to release and disclose all psychotherapy notes relating to me without restriction.
I understand that the Company will use the information it obtains to: (a) administer claims; (b) determine or fulfill responsibility for coverage and provision of benefits; (c) administer coverage; and/or (d) conduct other legally permissible activities that relate to any coverage I have or have applied for with the Company.
I understand that the Company will not disclose information it obtains about me except as authorized by this Authorization; as may be required or permitted by law; or as I may further authorize. I understand that if information is redisclosed as permitted by this Authorization, it may no longer be protected by applicable federal privacy law.
I understand that: (a) this Authorization shall be valid for 24 months from the date I sign it; (b) I may revoke it at any time by providing written notice to Sun Life (N.Y.), Group Short Term Disability Claims Department, SC3212, One Sun Life Executive Park, Wellesley Hills, Massachusetts, 02481, subject to the rights of any person who acted in reliance on it prior to
receiving notice of its revocation; and (c) my authorized representative and I are entitled to receive a copy of the Authorization upon request.
A copy of this Authorization shall be as valid as the original. Print Name of Employee or Personal Representative of Employee
Group Policy Number
If Representative, description of your authority or relationship to employee
Signature of Employee or Personal Representative X
Date
Sun Life Insurance and Annuity Company of New York is a member of the Sun Life Financial group of companies.
© 2005 Sun Life Insurance and Annuity Company of New York, New York, NY 10165. All rights reserved.
Sun Life Insurance and Annuity Company of New York Customer Service Center
Wellesley Hills, MA 02481 1-800-247-6975
PRIVACY INFORMATION NOTICE
This notice explains why Sun Life Insurance and Annuity Company of New York (“the Company”) collects personal information about you, how we use that information, and under what circumstances we disclose it to others.
COLLECTION OF INFORMATION
We need to obtain information about you to determine whether we can provide the insurance benefits you have requested. As part of the claims process, we may ask you to undergo a physical examination, submit a statement from your physician, or provide copies of medical tests or other information relating to your health, finances and activities.
We also may collect information about you from other sources. By signing the Authorization For Release And Disclosure of Health Related Information and/or the Authorization For Release And Disclosure of Psychotherapy Notes, you authorize us to obtain medical information about you that we need to underwrite your application. Depending upon your particular
circumstances, we may collect additional information about you from the following sources:
• Physicians, health care providers, medical professionals, hospitals, clinics or other medical or healthcare related facilities
• Other insurance companies you have applied to for insurance
• Public records, such as Social Security and tax records DISCLOSURE OF PERSONAL INFORMATION
When you sign the Authorization For Release And Disclosure of Health Related Information and/or the Authorization For Release And Disclosure of Psychotherapy Notes, you authorize us to disclose information we have about you:
• To our reinsurers
• As required or permitted by law
In the course of the claims process, we may need to disclose information about you to others. The law permits us to disclose such information, without obtaining authorization from you, to:
• Companies that help us conduct our business or perform services on our behalf
• Your physician or treating medical professional
• Comply with federal, state or local laws, respond to a subpoena or comply with an inquiry by a government agency or regulator
ACCESS, CORRECTION AND AMENDMENT OF PERSONAL INFORMATION Upon written request to the Company, you can:
• Obtain a copy of the personal recorded information we have about you in our files (a fee may be charged to cover the cost of providing a copy of such information)
• Request that we correct, amend or delete any recorded personal information about you in our possession
• File your own statement of facts if you believe that the recorded personal information we have about you is incorrect To take any of these actions, please contact us at the following address for further instructions:
Sun Life Insurance and Annuity Company of New York Group Short Term Disability Claims
P.O. Box 81915
Wellesley Hills, MA 02481
